500 Montgomery Street, Suite 400, Alexandria, VA 22314 703-748-4900 firstname.lastname@example.org
Informed Consent/Office Policies
INFORMED CONSENT AND OFFICE POLICIES (January 1, 2013)
(1) Confidentiality The nature and content of all sessions is strictly confidential and will not be released unless you give your permission in writing. There are some exceptions you need to know about:(1) Insurance reimbursement claim forms have to give code numbers for your diagnosis and service rendered.(2)Information about your account (not about your case) will be released if unpaid balances are turned over for collection. (3) If you make a claim in court that someone has caused you emotional harm or if you file a petition or response in connection with custody or visitation, your records can be released. (4) Other situations are rare and include:reasonable suspicion of abuse of a child or incapacitated adult; actual threat of physical violence against a clearly or reasonably identified victim; evidence that you pose a danger to yourself; substantial evidence of commission of a crime.If presented with a request about you for a security clearance, I must verify your permission, so please make sure I have your contact info after our work has ended if I am going to be contacted by an investigator.
(2)Scheduling and Cancellations Your appointments are reserved for you.Sessions are 45-50 minutes unless longer sessions are arranged.Because of limited available hours for scheduling, you will be charged for non-emergency (e.g., work, schedule conflicts) cancellations made with less than a full MONTH in advance. Emergency cancellations, for sickness or weather, are not charged. No charge for rescheduling within the same day. If you are late, you will still be charged for a full session. If Dr. Criswell is late (rare), you will get the full session. _____PLS INITIAL THIS POLICY
(3)Payment and Use of Insurance Payment is required at each session by check, cash, or Paypal. Psychological evaluation reports must be paid for in advance.There is a $25 charge for a bounced check.Unpaid balances incur a late fee of $5 per week (up to 6 days, no late fee).Dr. Criswell uses a collection service on accounts past due over 30 days. If your account is sent for collection, your account balance will be increased by $25, plus the service charges you a fee of 33%.Many insurance policies will reimburse you for Dr. Criswell's services.For reimbursement, you pay Dr. Criswell directly, then submit your receipt for reimbursement.The terms of your policy are between you and your plan.Some services, such as filling out FMLA forms or writing special letters, are not covered by insurance.
(4) Mutual Responsibility My responsibility is to provide you a private space, dedicated time, and the best psychological services I can.Your responsibility is to show up and try your best.Many people make significant progress when they try. I have read and agree to the above policies: